Question 5161)
A child with appendicitis is scheduled for surgery this evening. The nurse enters the room and sees the child’s mother starting to place hot, wet washcloths on her daughter’s abdomen so that “she will feel better.” The nurse explains that this action is contraindicated because heat:
A. can cause the appendix to rupture and cause peritonitis.
B. can mask symptoms of acute appendicitis
C. will increase peristalsis throughout the abdomen.
D. will arrest progression of the disease.
Answer: A
Explanation: Heat can cause drawing of the inflammation and rupture of the appendix, which will cause peritonitis. Heat is not likely to mask the symptoms of appendicitis, increase peristalsis, or arrest progression of the disease.
Question 5162)
A client returns from having had abdominal surgery. Her vital signs are stable. She says she is thirsty. What should the nurse give her initially?
A. Orange juice
B. Milk
C. Ice chips
D. Mouth wash
Answer: C
Explanation: Ice chips can be given to help relieve thirst. Only clear liquids will be given until peristalsis has returned; milk and orange juice are not clear liquids. Mouth wash is not consumed and, when used appropriately, does not relieve thirst. It may freshen the mouth but does not relieve thirst.
Question 5163)
The client who has had an appendectomy and has a Penrose drain in place has recovered from anesthesia. The nurse places her in a semi-sitting position. What is the primary reason for selecting this position?
A. To promote optimal ventilation
B. To promote drainage from the abdominal cavity
C. To prevent pressure sores from developing
D. To reduce tension on the suture line
Answer: B
Explanation: The client has a Penrose drain in place. The primary reason for the semi-sitting position is to promote drainage. This position may also help reduce tension on the suture line and promote ventilation. Turning will help prevent pressure sores.
Question 5164)
The client is admitted to the hospital complaining of malaise, abdominal discomfort, and severe diarrhea. The diagnosis is possible Crohn’s disease. The client says that he has lost 27 pounds in the last four months even though he has not been dieting. To plan nursing care, which assessment data are most essential for the nurse to obtain?
A. Approximate number and characteristics of stools each day
B. Amount of liquid consumed daily
C. History of previous gastric surgery
D. Bowel sounds in the right lower quadrant
Answer: A
Explanation: It is most important for the nurse to know how many stools he has been having each day. Frequent stools are characteristic of Crohn’s disease and may cause dehydration and skin breakdown. The nurse may want to know how much liquid he has been consuming, but that is not the most important information. Previous gastric surgery is not usually related to Crohn’s disease. Bowel sounds may be assessed but are not the most important assessment data.
Question 5165)
The nurse is preparing a client with Crohn’s disease for discharge. Which of the following statements indicates that he needs further teaching?
A. “Stress can make it worse.”
B. “Since I have Crohn’s disease, I don’t have to worry about colon cancer.”
C. “I realize I shall always have to monitor my diet.”
D. “I understand there is a high incidence of familial occurrence with this disease.”
Answer: B
Explanation: Persons with Crohn’s disease are at high risk for the development of colon cancer. The other answers are all correct and therefore do not indicate a need for more instruction.
Question 5166)
A low-residue diet is ordered for a client. Which food would be contraindicated for this person?
A. Roast beef
B. Fresh peas
C. Mashed potatoes
D. Baked chicken
Answer: B
Explanation: Fresh peas are high in residue. Roast beef, mashed potatoes, and baked chicken are not high in residue. High-residue foods are those that contain skins, seeds, and leaves. Milk products are also to be avoided on a low-residue diet.
Question 5167)
A client is to have a sigmoidoscopy in the morning. Which activity will be included in the care of this client?
A. Give him an enema one hour before the examination
B. Keep him NPO for eight hours before the examination.
C. Order a low-fat, low-residue diet for breakfast.
D. Administer enemas until the returns are clear this evening.
Answer: A
Explanation: An enema one hour before the exam will clear the sigmoid colon. A client having an upper GI series will be NPO. A low-fat diet is indicated prior to a gallbladder series. A low-residue diet is part of the preparation for a barium enema. Enemas until clear are sometimes ordered prior to a barium enema or colonoscopy.
Question 5168) A client had a barium enema. Following the barium enema, the nurse should anticipate an order for which of the following?
A. An antacid
B. A laxative
C. A muscle relaxant
D. A sedative
Answer: B
Explanation: Barium can be very constipating and may cause blockage of the bowel. Laxatives help to empty the bowel of barium. The other drugs are not appropriate following a barium enema
Question 5169)
A client is found to have colon cancer. An abdominoperineal resection and colostomy are scheduled. Neomycin is ordered. The nurse explains to the client that the primary purpose for administering this drug is to:
A. decrease peristalsis in the intestines.
B. decrease the bacterial content in the colon.
C. reduce inflammation of the bowel.
D. help prevent postoperative pneumonia.
Answer: B
Explanation: Neomycin is an antibiotic that is poorly absorbed from the GI tract and will therefore kill the bacteria in the bowel. This must be done before colon surgery to prevent peritonitis. Neomycin is an antibiotic and does not decrease peristalsis or reduce inflammation. Because it is not absorbed from the bowel, it does not kill bacteria outside the GI tract and therefore will not prevent pneumonia.
Question 5170)
The day after surgery in which a colostomy was performed, the client says, “I know the doctor did not really do a colostomy.” The nurse understands that the client is in an early stage of adjustment to the diagnosis and surgery. What nursing action is indicated at this time?
A. Agree with the client until the client is ready to accept the colostomy
B. Say, “It must be difficult to have this kind of surgery.”
C. Force the client to look at his colostomy
D. Ask the surgeon to explain the surgery to the client
Answer: B
Explanation: The first stage of major loss is usually denial. The client is denying the colostomy. This empathic response encourages the client to discuss feelings. The nurse should never agree with the client’s denial. The denial should not be confronted at this point in time. He needs time to adjust. Notice that the stem of the question focuses on the denial stage.
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